P. 438

An Urban Experience
Routinely a bandage is applied after reconstruction of distal limb wounds. The bandage consists of a padded material in combination with an elastic protective
outer surface material (such as Vetrap). Suf cient pain medication can be combined with broadspectrum antibiotic therapy if necessary. Penrose drains are routine used in skin reconstruction techniques, such as the toe  let technique. The normal size Penrose may be adapted to the size of the  ap.
The mesh graft is a nonvascularised skin  ap that uses skin from another part of the body, which is transferred to the recipient defect side. Because of the nonvascularised nature of the  ap extreme care should be taken in fast and atraumatic harvesting and attachment of the  ap. This requires to surgical teams. One to prepare the wound bed an one harvesting the  ap and closing the donor defect. Teamwork is of the essence.
Types of mesh grafts
There are two major types of mesh grafts, the full and partial thickness mesh graft. Partial thickness mesh grafts are often obtained using electrically operated mechanical dermatomes. Full thickness grafts are made using the scalpel blade as described here. Full thickness grafts have the advantage of better cosmetic end results (especially hair growth) above partial thickness grafts. Partial thickness grafts have a better change of taking and the donor sites do not to be sutured after the harvest.
Wound bed preparation
The wound bed needs to be prepared adequately to be able to receive the mesh graft. Preparation includes:
• Removing wound  uid, crusts, dead tissue and possible foreign bodies
• Inspecting the epithelial borders and if necessary cleaning up the wound edges
• Coagulation of possible bleeders
• Removing the top layer of the granulation tissue (if necessary)
The recipient side should be covered with a sa- line-soaked sponge to prevent dessication while the donor side is prepared.
Donor side preparation
The donor side should be carefully selected. It should have enough skin left over after the removal of the donor graft to close the defect. Also attention should be
directed to the growth pattern and colour of the hairs to be able to achieve the most acceptable cosmetic results. Often an impression is made of the recipient bed to estimate the size of the donor bed. The graft will expand signi cantly in correlation with the number of slits (or meshes) that are made in the graft. Using a non-meshed graft is discouraged. The mesh prevents  uid build-up under the graft. A seroma will signi cantly decrease the take (acceptance) of the graft.
It is important to keep the graft moistened during the complete procedure. The technique of a mesh graft is as follows:
• Prepare the site aseptically
• Use a skin marker to determine the margins of the graft
• Incise the skin along the drawn line
• Start at the bottom of the graft and elevate only the skin from the wound bed. The panniculus muscle is not incorporated into the graft
• Suture the edges of the graft to a sterilised roll of bandage material (such as Vetwrap form 3M)
• Use the roll to put tension on the graft and lift it up from the donor bed.
• An eleven blade should be used to remove as much subcutis from the graft as possible (you should be able to see the hair follicles)
• Slowly roll the graft over the bandage material
• Attach the graft with a few sutures to the bandage material
• Remove the complete graft and free it from the subcutaneous fat
• Use an eleven blade to make the mesh (slits) in the graft. The distance of the slits should be less than a cm and not in an even row but alternate between rows (see picture)
• Remove the graft from the bandage roll
• Place the graft as soon as possible on the prepared recipient side.
• Suture or staple the edges of the graft to the recipient side. Sutures are not necessary inside the graft edges.
After care
This is the most dif cult part of the procedure. A well padded, non-stick bandage that is able to absorb excess wound  uid should be applied and not removed fro 3-5 days. Meanwhile it needs to be kept as clean and dry
as possible. In this period plasmatic imbibition will take place and nuture the graft and vessels will be able to reconnect. After this very careful bandage changes will be necessary. The graft will adhere in 7-14 days and epithelialisation of the slits will take place within a month.

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